There is a duality to implementing EBP and become a culture of safety through a multi-prong focus. Organizations are obligated to create a culture of safety, quality, and care. A focal involvement of the organization enables the staff to optimize their performance through innovation, technology, and leadership.
Adverse outcomes and incidents serve as a conduit for change. Adverse outcomes within the clinical setting are often devastating to the patient, staff, and organization. These occurrences are called sentinel events. However, sentinel events press the organization to rectify all missed opportunities and improve the process or provide supportive education.
The Quality and Safety Education for Nurses (QSEN) project began in 2005 (QSEN, 2018). It was created because of two Institute of Medicine (IOM) reports that addressed not just the number, but also the types of medical errors in medical institutions across the United States (IOM, 2001; Kohn, Corrigan, & Donaldson, 1999). The IOM report (Kohn et al., 1999) cited a study that revealed that the number of Americans dying each year due to medical errors could be as high as 98,000. This statistic makes deaths due to medical errors the eighth leading cause of death in the U.S. More recently, deaths associated with preventable harm to patients were estimated at more than 400,000 per year (Chenot & Christopher, 2019).
The statistics from these findings resulted in a call for a new and different skillset for health professionals such as: